CMS Firmly Opposed to Lifetime Limits on Medicaid

"We have made that pretty clear to states," says Seema Verma

WASHINGTON -- The Trump administration is firmly opposed to lifetime limits on Medicaid benefits, Seema Verma, the administrator of the Centers for Medicare & Medicaid Services (CMS), said Tuesday.

"What we have approved is temporary lapses in coverage, so an individual may not comply with [for example] a requirement around cost-sharing and potentially lose coverage, but we want to make sure there's a pathway back into the program," Verma said at an event on the future of healthcare sponsored by the Washington Post. When CMS recently turned down Kansas' request for a 3-year lifetime limit for its Medicaid recipients, "We indicated we would not approve lifetime limits, and have made that pretty clear to states."

Although the agency opposes lifetime limits, it is encouraging states that want to include some form of work requirement -- known at CMS as "community engagement" -- for able-bodied adults in the Medicaid program. Community engagement programs generally require recipients to either be working, going to school, or volunteering in the community; the elderly, recipients with disabilities, and children are exempted.

Verma noted that other federal-state programs such as the Supplemental Nutrition Assistance Program (SNAP) and Temporary Assistance for Needy Families (TANF) also include work requirements.

"In the SNAP and TANF programs, if an individual is in the program for 3 years ... afterwards they have to engage in community engagement to retain those benefits; we're comfortable with that approach," she said, adding that CMS would like to see states align their Medicaid work requirements with SNAP and TANF because "we didn't want individuals to have two sets of requirements."

But Medicaid must always be available for those who need it, Verma said. "In the Medicaid program, you're dealing with a fragile population and there are changes in their lives -- they may be able to go into a community engagement program, get a job, [and become] independent, but circumstances change, and we always want to make sure the program serves as a safety net and there's a place for people to go if they need it."

Verma took pains to distinguish the two different types of populations in the Medicaid program now that some states have expanded it. For the Medicaid expansion population, which mostly includes able-bodied individuals, "the goal should be not only to provide healthcare coverage but also to provide a pathway out of poverty. It is a success for us if people are able to rise out of poverty ... and no longer need the program."

She was more circumspect about a request from the state of Wisconsin to test its Medicaid recipients for drugs. "Our nation is in the middle of an opioid epidemic," Verma said. "We are very focused on developing strategies to try to address the epidemic. When we look at some things that states want to do ... It's understanding where is it you want to go; what goals do you want to achieve? For a lot of states, what they're looking at is they want to be able to identify individuals that need help ... What's the best way to identify individuals and link them to services that are most appropriate?"

States may want to consider "ideas around risk assessment and not only identifying substance abuse but also [performing] a comprehensive health assessment to look at all the health issues a person may be facing," she said.

Former surgeon general Vivek Murthy, MD, who also spoke at the event, suggested that the nation needs to look more deeply at why the opioid epidemic and other substance use disorders are occurring. "There's a deeper pain that people are experiencing, a deeper despair in their lives, that is temporarily being assuaged not just by opioids but also alcohol [and other substances]," he said. "We need to think more deeply about the root causes of addiction... it's in many ways as much a social disease as much as biological disease."

Murthy praised the progress that had been made so far. "We're reducing prescribing of opioids ... and we're also seeing progress in extending medication-assisted treatment" with drugs such as buprenorphine, he said. "There are still far too many people who need treatment and can't get it, but in places like Rhode Island, the state has now moved to make medication-assisted treatment available in the prison system ... [resulting in a] reduction in overdose deaths by nearly 12% statewide in Rhode Island in just a year."

However, more investment is needed in "upstream prevention programs -- programs we wrote about in our Surgeon General's report -- which are often school- and community-based and relatively inexpensive to administer, but can have a dramatic impact on drug use among children, adolescents and adults," Murthy said. For example, for every dollar spent instituting the Good Behavior Game to improve classroom cohesion results in a $64 reduction in healthcare costs, criminal justice costs, and lost economic productivity.

"We also need to think about what's an appropriate role each of us has to play" in shifting the culture around addiction, he said. Often, people have the attitude "that this is a disease of choice ... That is not the case. It is often just dependent on the circumstance in which we live. If we can change culture, we can change a lot of other things. This is what we have to do."

"The role the federal government needs to play is a role in setting a vision and benchmark for where we need to go on opioids," Murthy added. "How much are we trying to reduce opioid deaths in the next 1 year, 5 years? I don't think that's been stated clearly. How are we holding states and the federal government accountable for doing the work that needs to be done ... for changing outcomes? This is a place where government has to step up."

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